Usefulness of the Surgical Apgar Score to Predict the Occurrence of Major Complications in the Early Post-Operative Period of Major Surgeries: Experience of Two Second-Category Hospitals in Cameroon

Objective: The Surgical Apgar Score (SAS) is a tool for intraoperative stratification of the risk of serious complications in the early postoperative period. It varies from 0 to 10 points divided into three risk categories (0 to 4 high, 5 to 7 moderate, 8 to 10 low). The aim of the study was to evaluate its relevance in predicting the appearance of these complications. Material and methods: This descriptive and analytical study was carried out at the “Laquintinie” Hospital in Douala and at the Central Hospital in Yaounde, Cameroon. The main data were collected on a population of patients over 18 years old and recorded on a survey form. They consisted of variables of main interest and exposure variables. Univariate and multivariate statistical analysis using top-down logistic regression models made it possible to evaluate the association of each variable of main interest and each exposure variable. The association was significant at P Results: Of the 88 patients studied, the SAS was 3 hours. In multivariate, this link persisted only and strongly for the SAS OR (IC) 0.1 (0.1 - 0.2) and p = 000. Conclusion: The study found a specific and powerful link between the SAS score < 4 and the occurrence of complications in the early postoperative period, in favor of its relevance in predicting them.

Prevention of complications in endourological management of stones:What are the basic measures needed before,during,and after interventions?

Objective:This narrative review aims to describe measures to minimise the risk of complications during percutaneous nephrolithotomy(PCNL),ureteroscopy,and retrograde intrarenal surgery.Methods:A literature search was conducted from the PubMed/PMC database for papers published within the last 10 years(January 2012 to December 2022).Search terms included“ureteroscopy”,“retrograde intrarenal surgery”,“PCNL”,“percutaneous nephrolithotomy”,“complications”,“sepsis”,“infection”,“bleed”,“haemorrhage”,and“hemorrhage”.Key papers were identified and included meta-analyses,systematic reviews,guidelines,and primary research.The references of these papers were searched to identify any further relevant papers not included above.Results:The evidence is assimilated with the opinions of the authors to provide recommendations.Best practice pathways for patient care in the pre-operative,intra-operative,and post-operative periods are described,including the identification and management of residual stones.Key complications(sepsis and stent issues)that are relevant for any endourological procedure are then be discussed.Operation-specific considerations are then explored.Key measures for PCNL include optimising access to minimise the chance of bleeding or visceral injury.The role of endoscopic combined intrarenal surgery in this regard is discussed.Key measures for ureteroscopy and retrograde intrarenal surgery include planning and technique to minimise the risk of ureteric injury.The role of anaesthetic assessment is discussed.The importance of specific comorbidities on each step of the pathway is highlighted as examples.Conclusion:This review demonstrates that the principles of meticulous planning,interdisciplinary teamworking,and good operative technique can minimise the risk of complications in endourology.

Immediate secondary rhinoplasty using a folded dermofat graft for resolving complications related to silicone implants: A case report

BACKGROUND Various surgical techniques have been developed to enhance the nose shapes of Asian patients.Silicone implant augmentation rhinoplasty is widely used because it is relatively easy to perform and often yields satisfactory outcomes.However,this technique may lead to complications,including ischemia,necrosis,and over-augmentation.The most appropriate management of these complications,including infection,is immediate implant removal and revision surgery once the accompanying inflammation has healed.Occasionally,the patient may experience distress from nasal deformities during the intervention period.CASE SUMMARY Herein,we describe the case of a patient who underwent a secondary dorsal augmentation,with a folded dermofat graft harvested from the inguinal area and simultaneous implant removal,successfully preventing dimpling of the nasal deformity.CONCLUSION This surgical method can effectively manage implant-related complications following augmentation rhinoplasty using a silicone implant and provide satis-factory patient outcomes.

Early postoperative complications after transverse colostomy closure,a retrospective study

BACKGROUND Ostomy is a common surgery usually performed to protect patients from clinical symptoms caused by distal anastomotic leakage after colorectal cancer(CRC)surgery and perforation or to relieve intestinal obstruction.AIM To analyze the complications after transverse colostomy closure.METHODS Patients who underwent transverse colostomy closure from Jan 2015 to Jan 2022 were retrospectively enrolled in a single clinical center.The differences between the complication group and the no complication group were compared.Logistic regression analyses were conducted to find independent factors for overall complications or incision infection.RESULTS A total of 102 patients who underwent transverse colostomy closure were enrolled in the current study.Seventy(68.6%)patients underwent transverse colostomy because of CRC related causes.Postoperative complications occurred in 30(29.4%)patients and the most frequent complication occurring after transverse colostomy closure was incision infection(46.7%).The complication group had longer hospital stays(P<0.01).However,no potential risk factors were identified for overall complications and incision infection.CONCLUSION The most frequent complication occurring after transverse colostomy closure surgery in our center was incision infection.The operation time,interval from transverse colostomy to reversal,and method of anastomosis might have no impact on the postoperative complications.Surgeons should pay more attention to aseptic techniques.

Impact of the Rapid Recovery Concept on Complications and Patient Quality of Life in the Perioperative Nursing of Robot-Assisted Radical Oesophageal Cancer

Aim: This study evaluates the impact of Enhanced Recovery After Surgery (ERAS) nursing on postoperative complications and quality of life in patients undergoing robot-assisted minimally invasive esophagectomy (RAMIE). Methods: A total of 150 patients who underwent RAMIE from January 2020 to January 2022 at our hospital were randomly assigned to either the observation group or the control group, with 75 patients in each. The control group received standard perioperative management and nursing care, while the observation group was treated with ERAS nursing strategies. Interventions continued until discharge, and outcomes such as postoperative complications, quality of life, and nutritional status were compared between the groups. Results: The observation group exhibited a significantly lower incidence of postoperative adverse reactions compared to the control group (P ionally, all dimension scores of the Short-Form 36 Health Survey (SF-36), including the total score, were higher in the observation group (P < 0.05). Furthermore, the Nutritional Risk Screening (NRS) scores for impaired nutritional status and disease severity, along with the total NRS score, were significantly lower in the observation group compared to the control group (P Conclusion: Implementing ERAS nursing in the perioperative care of patients undergoing RAMIE is associated with reduced postoperative complications and enhanced postoperative quality of life and nutritional status. .

Biliary complications associated with weight loss,cholelithiasis and choledocholithiasis

Biliary complications like cholelithiasis and choledocholithiasis are more common in bariatric surgery patients due to obesity and rapid weight loss.Patients with a body mass index>40 face an eightfold risk of developing cholelithiasis.Postbariatric surgery,especially after laparoscopic Roux-en-Y gastric bypass(LRYGB),30%of patients develop biliary disease due to rapid weight loss.The aim of this review is to analyze the main biliary complications that occur after bariatric surgery and its management.A review of the literature was conducted mainly from 2010 up to 2023 with regard to biliary complications associated with bariatric patients in SciELO,PubMed,and MEDLINE.Patients undergoing LRYGB have a higher incidence(14.5%)of symptomatic calculi post-surgery compared to those undergoing laparoscopic sleeve gastrectomy at 4.1%.Key biliary complications within 6 to 12 months post-surgery include:Cholelithiasis:36%;Biliary colic/dyskinesia:3.86%;Acute cholecystitis:0.98%-18.1%;Chronic cholecystitis:70.2%;Choledocholithiasis:0.2%-5.7%and Pancreatitis:0.46%-9.4%.Surgeons need to be aware of these complications and consider surgical treatments based on patient symptoms to enhance their quality of life.

Comparison of complication rates between femtosecond laser-assisted cataract surgery and conventional phacoemulsification cataract surgery

Dear Editor,We read with interest the Meta-analysis conducted by Chen et al[1]on the clinical outcomes and complication rates between femtosecond laser-assisted cataract surgery(FLACS)and conventional phacoemulsification cataract surgery(CPCS).The authors reported no statistical difference between both methods for all measured complications except posterior capsular tear,with CPCS displaying a higher rate of posterior capsular tear.Since its inception in 2011[2].

Analysis of the impact of ERAS-based respiratory function training on older patients’ability to prevent pulmonary complications after abdominal surgery

BACKGROUND In China,as the population grows older,the number of elderly people who have died from respiratory problems has increased.AIM To investigate whether enhanced recovery after surgery(ERAS)-based respiratory function training may help older patients who had abdominal surgery suffer fewer pulmonary problems,shorter hospital stays,and improved lung function.METHODS The data of 231 elderly individuals having abdominal surgery was retrospectively analyzed.Based on whether ERAS-based respiratory function training was provided,patients were divided into ERAS group(n=112)and control group(n=119).Deep vein thrombosis(DVT),pulmonary embolism(PE),and respiratory tract infection(RTI)were the primary outcome variables.Secondary outcome variables included the Borg score Scale,FEV1/FVC and postoperative hospital stay.RESULTS The percentage of 18.75%of ERAS group participants and 34.45%of control group participants,respectively,had respiratory infections(P=0.007).None of the individuals experienced PE or DVT.The ERAS group’s median postoperative hospital stay was 9.5 d(3-21 d)whereas the control groups was 11 d(4-18 d)(P=0.028).The Borg score decreased on the 4th d following surgery in the ERAS group compared to the 2nd d prior(P=0.003).The incidence of RTIs was greater in the control group than in the ERAS group among patients who spent more than 2 d in the hospital before surgery(P=0.029).CONCLUSION ERAS-based respiratory function training may reduce the risk of pulmonary complications in older individuals undergoing abdominal surgery.

Reoperation for early postoperative complications after gastric cancer surgery in a Chinese hospital

AIM:To investigate the occurrence of postoperative complications of gastric cancer surgery,and analyze the potential causes of reoperation for early postoperative complications. METHODS:A total of 1639 patients who underwent radical or palliative gastrectomies for gastric cancer were included in the study.The study endpoint was the analysis of postoperative complications in inpatients. RESULTS:About 31%of patients had early postoperative complications,and complications of infection occurred most frequently.Intra-abdominal hemorrhage and anastomotic leak were the main causes of reoperation,which accounted for about 2.2%.Mortality was 11.1%in the reoperation group,but was only 0.8%in other patients.The duration of postoperative stay in hospital was significantly longer and the total expenditure was markedly higher in the patients who underwent reoperation(P<0.001).There was no significant association of any available factors in this study with the high rate of reoperation.CONCLUSION:Reoperation significantly increases the mortality rate and raises the burden of the surgical unit.More prospective studies are required to explore the potential risk factors.

Comparing the intraoperative complication rate of femtosecond laser-assisted cataract surgery to traditional phacoemulsification

AIM: To compare the complication rate of femtosecond laser-assisted cataract surgery(FLACS) and traditional phacoemulsification for the first 18 mo of FLACS use at a private surgical center in Hawaii.METHODS: A retrospective chart review was conducted from January 2012 to June 2013. The first 273 consecutive eyes receiving FLACS and 553 eyes receiving traditional phacoemulsification were examined.All surgeries were performed at a single surgical center in Hawaii. The presence of intraoperative complications was used as the main outcome measure. Approval was obtained from the institutional review board of the University of Hawaii.RESULTS: The overall complication rate for FLACS was 1.8%, while that of the traditional procedure was5.8%(P 【0.05). A majority of the surgeons(80%) had a lower complication rate while using FLACS.CONCLUSION: FLACS is comparable in safety, if not safer, than traditional cataract surgery when performed by qualified cataract surgeons on carefully selected patients.

Positioning patients for spine surgery: Avoiding uncommon position-related complications

Positioning patients for spine surgery is pivotal for optimal operating conditions and operative-site exposure. During spine surgery, patients are placed in positions that are not physiologic and may lead to complications. Perioperative peripheral nerve injury(PPNI) and postoperative visual loss(POVL) are rare complications related to patient positioning during spine surgery that result in significant patient disability and functional loss. PPNI is usually due to stretch or compression of the peripheral nerve. PPNI may present as a brachial plexus injury or as an isolated injury of single nerve, most commonly the ulnar nerve. Understanding the etiology, mechanism and pattern of injury with each type of nerve injury is important for the prevention of PPNI. Intraoperative neuromonitoring has been used to detect peripheral nerve conduction abnormalities indicating peripheral nerve stress under general anesthesia and to guide modification of the upper extremity position to prevent PPNI. POVL usually results in permanent visual loss. Most cases are associated with prolonged spine procedures in the prone position under general anesthesia. The most common causes of POVL after spine surgery are ischemic optic neuropathy and central retinal artery occlusion. Posterior ischemic opticneuropathy is the most common cause of POVL after spine surgery. It is important for spine surgeons to be aware of POVL and to participate in safe, collaborative perioperative care of spine patients. Proper education of perioperative staff, combined with clear communication and collaboration while positioning patients in the operating room is the best and safest approach. The prevention of uncommon complications of spine surgery depends primarily on identifying high-risk patients, proper positioning and optimal intraoperative management of physiological parameters. Modification of risk factors extrinsic to the patient may help reduce the incidence of PPNI and POVL.

Pulmonary complications after spine surgery

Spine surgery is one of the fastest growing branches of orthopedic surgery. Patients often present with a relatively high acuity and, depending on surgical approach, morbidity and mortality can be comparatively high. Among the most prevalent and most frequently fatalitybound perioperative complications are those affecting the pulmonary system; evidence of clinical or subclinical lung injury triggered by spine surgical procedures is emerging. Increasing burden of comorbidity among the patient population further increases the likelihood of adverse outcome. This review is intended to give an overview over some of the most important causes of pulmonary complications after spine surgery, their pathophysiology and possible ways to reduce harm associated with those conditions. We discuss factors surrounding surgical trauma, timing of surgery, bone marrow and debris embolization, transfusion associated lung injury, and ventilator associated lung injury.

Association between anesthesia technique and complications after hip surgery in the elderly population

BACKGROUND Spinal anesthesia is superior to general anesthesia for postoperative recovery in older patients(≥65 age).However,evidence for this is lacking.AIM To evaluate the effect of anesthesia on postoperative complications in older patients undergoing hip surgery.METHODS This is a retrospective,propensity score-matched,cohort study.Patients≥65-years-old who underwent hip surgery at the Traditional Chinese Medicine of Guangdong Provincial Hospital in China from October 2016 to June 2020 were included.The operative methods were femoral fracture’s internal fixation and hip replacement.The orthopedic doctors in different hospitals of our group have varied requirements for patients’out-of-bed time after surgery.Therefore,spinal anesthesia or general anesthesia was selected according to the requirements of the orthopedic doctors.The primary outcome of this study was complications during the hospitalization of the postoperative patient.The length of hospital stay,postoperative blood transfusion,routine blood analysis,renal function,coagulation function,and inflammatory correlations were secondary outcomes.Propensity score matching(PSM)was performed utilizing logistic regression.RESULTS Among the 864 patients identified from the electronic medical record data database,we screened out those with incomplete medical record data.After PSM of the baseline values of the two groups of patients,data of 309 patients(206 patients in spinal anesthesia group and 103 patients in general anesthesia)were utilized in this study.67/309 patients had complications,including postoperative limb dysfunction,pulmonary infection,delirium,lower extremity venous thrombosis,and shock.The incidence of complications was not related to anesthesia methods(P>0.05),but the levels of D-Dimer(P=0.017),fibrinogen(P=0.005),and high-sensitivity C-reactive protein(hs CRP)(P=0.002)in the spinal anesthesia group were significantly higher than those in the general anesthesia group.CONCLUSION Anesthesia technology is not a risk factor for postoperative complications of hip surgery.The levels of D-Dimer and hs CRP were higher in the spinal anesthesia group.

Common surgical complications in degenerative spinal surgery

The rapid growth of spine degenerative surgery has led to unrelenting efforts to define and prevent possible complications, the incidence of which is probably higher than that reported and varies according to the region of the spine involved(cervical and thoracolumbar) and the severity of the surgery. Several issues are becoming progressively clearer, such as complication rates in primary versus revision spinal surgery, complications in the elderly, the contribution of minimally invasive surgery to the reduction of complication rate. In this paper the most common surgical complications in degenerative spinal surgery are outlined and discussed.

Early Post-Operative Complications in Surgeries Pertaining Oral and Maxillofacial Region in MNH, Tanzania

The Oral and maxillofacial region is one of the complex regions of the body considering the vast anatomical structures that are found in this region;head and neck surgery has potential for many complications, yet inadequate information on occurrence of post-operative complications in oral and maxillofacial surgeries in our setting has been documented. The aim of this study was to determine the occurrence of common early post-operative complications after oral and maxillofacial surgery in relationship to the underlying systemic condition. A descriptive postoperative study was done whereby patients who underwent oral and maxillofacial surgery were included. The included patients were those who underwent surgery for different pathological conditions, trauma, developmental/congenital conditions and inflammatory conditions to mention few. Demographic data, complications developed within one week post operative, and underlying systemic comorbidities before and after surgery were documented and analysed. A total of 102 patients were included in the study. The mean age of participants was 30.00 ± 17.01 years with a range of 2 to 81 years. Majority 43.1% (n = 44) had benign tumors with a leading diagnosis of ameloblastoma. In general, the most common complications which were noted in the cases included Pain 98% (n = 100) and Post-operative Swelling 97.1% (n = 99). The presence of underlying systemic comorbid conditions has a significant role in occurrence of some severe complications. The occurrence of complications does increase the duration of stay in the hospital hence increasing cost of treatment for which bearers are both patients and the hospital.

Orthopedic surgery and its complication in systemic lupus erythematosus

Systemic lupus erythematosus(SLE) is a multi-systemic immune-complex mediated autoimmune condition which chiefly affects women during their prime year. While the management of the condition falls into the specialty of internal medicine, patients with SLE often present with signs and symptoms pertaining to the territory of orthopedic surgery such as tendon rupture, carpal tunnel syndrome, osteonecrosis, osteoporotic fracture and infection including septic arthritis, osteomyelitis and spondylodiscitis. While these orthopedicrelated conditions are often debilitating in patients with SLE which necessitate management by orthopedic specialists, a high index of suspicion is necessary in diagnosing these conditions early because lupus patients with potentially severe orthopedic conditions such as osteomyelitis frequently present with mild symptoms and subtle signs such as low grade fever, mild hip pain and back tenderness. Additionally, even if these orthopedic conditions can be recognized, complications as a result of surgical procedures are indeed not uncommon. SLE per se and its various associated pharmacological treatments may pose lupus patients to certain surgical risks if they are not properly attended to andmanaged prior to, during and after surgery. Concerted effort of management and effective communication among orthopedic specialists and rheumatologists play an integral part in enhancing favorable outcome and reduction in postoperative complications for patients with SLE through thorough pre-operative evaluation, careful peri-operative monitoring and treatment, as well as judicious postoperative care.

Endoluminal solutions to bariatric surgery complications:A review with a focus on technical aspects and results

Obesity is a growing problem in developed countries,and surgery is the most effective treatment in terms of weight loss and improving medical comorbidity in a high proportion of obese patients.Despite the advances in surgical techniques,some patients still develop acute and late postoperative complications,and an endoscopic evaluation is often required for diagnosis.Moreover,the high morbidity related to surgical reintervention,the important enhancement of endoscopic procedures and technological innovations introduced in endoscopic equipment have made the endoscopic approach a minimally-invasive alternative to surgery,and,in many cases,a suitable first-line treatment of bariatric surgery complications.There is now evidence in the literature supporting endoscopic management for some of these complications,such as gastrointestinal bleeding,stomal and marginal ulcers,stomal stenosis,leaks and fistulas or pancreatobiliary disorders.However,endoscopic treatment in this setting is not standardized,and there is no consensus on its optimal timing.In this article,we aim to analyze the secondary complications of the most expanded techniques of bariatric surgery with special emphasis on those where more solid evidence exists in favor of the endoscopic treatment.Based on a thorough review of the literature,we evaluated the performance and safety of different endoscopic options for every type of complication,highlighting the most recent innovations and including comparative data with surgical alternatives whenever feasible.

Gallbladder plication as a rare complication of endoscopic sleeve gastroplasty:A case report

Endoscopic sleeve gastroplasty(ESG)is a minimally invasive procedure used in the treatment of obesity,with a complication rate of less than 2%of cases.There have been only two reported cases worldwide of gallbladder injuries as a major complication of ESG.CASE SUMMARY We present the case of a 34-year-old patient who developed a complication after ESG.The patient experienced epigastric and right hypochondrium pain 12 h after the procedure,and a positive Murphy’s sign was identified on physical examination.Laboratory results showed a leukocyte count of 17×10^(3)/μL,and computed tomography indicated the presence of free fluid in the pelvic cavity and perihepatic recesses as well as a possible suture in the wall of the Hartmann’s pouch toward the anterior surface of the stomach.A diagnostic laparoscopy was performed,revealing plication of the Hartmann’s pouch wall to the anterior stomach wall.Laparoscopic cholecystectomy and lavage were carried out.The patient had a stable recovery and was discharged 72 h after surgery,tolerating oral intake.CONCLUSION Gallbladder plication should be suspected if signs and symptoms consistent with acute cholecystitis occur after ESG.

Clinical outcomes and complications of single anastomosis duodenal-ileal bypass with sleeve gastrectomy:A 2-year follow-up study in Bogotá,Colombia

BACKGROUND The global prevalence of obesity has increased over the past 40 years,and bariatric surgery has proven to be the most effective therapy for long-term weight loss.Its principles are based on modifying the brain-gut axis by altering the gastrointestinal anatomy and affecting the function of gastrointestinal hormones,thereby modifying satiety signals.Single anastomosis duodeno-ileal bypass with sleeve gastrectomy(SADI-S)combines both techniques and has become an alternative to gastric bypass and biliopancreatic diversion procedures for treating severe obesity and associated metabolic diseases in selected patients.AIM To describe the outcomes and complications of SADI-S.METHODS We retrospectively analyzed the data of patients who underwent SADI-S laparoscopically at the Clínica Reina Sofía in Bogotá,Colombia.This study assessed the therapeutic effectiveness of SADI-S in terms of short-term preoperative clinical characteristics,postoperative complications,comorbidities,nutritional deficiencies,and intraoperative complications during a 2-year follow-up.RESULTS Sixty-one patients with a mean body mass index(BMI)of 50±7.1 kg/m2 underwent laparoscopic SADI-S.The mean operative time and hospital stays were 143.8±42 min and 2.3±0.8 d,respectively.The mean follow-up period was 18 mo,and the mean BMI decreased to 28.5±12.2 kg/m2.The excess BMI loss was 41.8%±13.5%,and the weight loss percentage was 81.1%±17.0%.Resolution of obesity-related comorbidities,including type 2 diabetes mellitus,hypertension,dyslipidemia,and obstructive sleep apnea,was achieved and defined as complete or partial remission.No intraoperative complications were observed.Short-term complications were observed in four(6.8%)patients.However,larger studies with longer follow-up periods are required to draw definitive conclusions.CONCLUSION SADI-S has a low intraoperative and postoperative complication rate and is effective for weight loss and improving obesity-related comorbidities,including hypertension,type 2 diabetes mellitus,dyslipidemia,and sleep apnea syndrome.

Urologic Complications after Gynaecologic and Obstetric Surgery at the Urology-Andrology Teaching Clinic of Teaching Hospital of Cotonou

Objective: To study the epidemiology and current trend in the management of urologic complications following obstetric and gynaecologic surgeries at CUUA University hospital of Cotonou. Patients and Methods: It was a retrospective study of patients referred with urologic complications following obstetric and gynaecological surgeries. The study took place at the Teaching Clinic of Urology Andrology at CNHU of Cotonou between April 1, 2008 and March 31, 2013. Results: Forty-one patients were studied. They represented 3.5% of people hospitalized at CUUA throughout the study period. The average age was 41 years swith range of 20 and 57 years. Twenty-one (51.2%) of them were married. Thirty patients (73.2%) were referred from a non-academichospital, while 7 patients (17.1%) were referred from academic hospital. Caesarean section was the primary gynecological surgery in 22 cases (53.7%) and hysterectomy in 19 cases (46.3%). Clinically, the pre- dominant symptoms were leakage of urine throughout the vagina and obstructive anuria with or without back pain. We found 31 cases of VVF, 5 cases of bilateral ligation of the ureters, 3 cases of unilateral ligation of the ureter, 1 ureteralinjury and 1 uretero-vaginal fistula. These complications were diagnosed postoperatively in 95.1% of cases. Surgeries done included VVF repair in 31 cases (75.6%), unilateral ureteral reimplantation in 4 cases (9.8%), removal of ligation of the ureters in 3 cases (7.3%), bilateral ureteral reimplantation for 2 cases (4.9%) and end-to-end anastomosisin 1 case (2.4%). The postoperative period was uneventful in 29 cases and we observed 7 cases of surgical site infection. The overall success rate was 87.8%. Conclusion: Urological complications following gynecologic surgeries managed at the urologic department of teaching hospital of Coto-nou had an even higher incidence. Early diagnosis especially during the operative procedure would save the patients’ serious complications and open surgery due to the lack of endo-urological facilities. The most important factor in prevention is good knowledge of pelvicanatomy and good knowledge of the surgical techniques of caesarean operation section and trans-abdominal hysterectomy.